Pandemic drove stake into primary care

Payment reform can save it

My wife and I, both in our 70s, scheduled our first COVID-19 vaccination shot for next week. Hooray! We got lucky because our 27-year-old daughter, who lives a thousand miles away, haunted enough websites until she found a hospital about 15 miles from our home that had open appointments.

We failed to find slots on either the Walgreens or CVS websites, despite my going online late at night, early in the morning and various times in between on multiple days over many weeks. Our primary care physicians, both affiliated with a major hospital system, were no help. Their system’s website said, in essence: “Don’t call us. We’ll call you.”

I’m not complaining. We’re both in relatively good health and I presume people who are at greater risk deservedly got their initial shot ahead of us. At least, I hope that’s the case.

But our experience highlights the sorry state of primary care. These crucial physicians, who should be everyone’s first entry point when they need healthcare, have been largely excluded from the initial phases of the vaccine distribution system.

I’m not surprised. Primary care has long been the stepchild of modern medicine, whose priorities remain focused on high-cost, technology-driven specialty care.

The COVID-19 pandemic has heightened the problems of primary care practices across the U.S. They remain financially dependent on fee-for-service visits by patients in immediate need of attention. As a result, they’ve been financially devastated by the pandemic. People halted virtually all non-emergency visits during last spring’s shutdowns and volumes still haven’t fully recovered as patients continue to postpone care.

Burnout

A new Perspective in the New England Journal of Medicine lays out the disastrous details. Anywhere from 20% to 40% of primary care physicians belong to practices that are considering sale, closure or consolidation with larger entities. Practices treating low-income clientele have been especially hard hit by service disruptions during the pandemic. There’s growing concern about the health consequences of millions of people, many with serious chronic conditions, postponing routine and preventive care.

The primary care field is also experiencing a high degree of burnout, which the NEJM Perspective blames on the “hamster-wheel” work environment created by fee-for-service medicine. “This retrospective, piecemeal approach to payment leaves clinicians trapped in a volume-maximizing culture that leads to rushed visits, wasteful practices, and high rates of clinician burnout. FFS payment also stifles innovation in care delivery and undermines integration with behavioral health and community services.”

The latest physician salary survey by Modern Healthcare reveals how the American Medical Association’s recommendations to Medicare for setting physician pay scales compounds the problems facing family practice physicians. The AMA’s ridiculously named Specialty Society Relative Value Scale Update Committee (the RUC) has more in common with early 20th century industrial time-and-motion studies than anything relevant to modern medicine.

The RUC evaluates the amount of time and skill it takes to perform discreet medical actions and procedures. Dominated by elite proceduralists (each specialty gets one vote), the committee systematically undervalues evaluation and management tasks, which over many decades turned family practice and pediatrics into the two lowest-paid specialties in medicine. Their average salary of a quarter million dollars a year may seem like a lot to most people, but it is half what high-paid specialists in cardiology, orthopedics and radiology earn.

The payment reform agenda

Over the past week, I listened in to or participated in several webinars on value-based medicine and payment reform. Those terms are medical economics jargon for dumping fee-for-service medicine in favor of alternative payment arrangements, the most far-reaching of which is some form of capitated payment where providers get a set per member per month fee for every patient under their care.

Under capitation, the physician practices or hospital systems receiving the flat fee must meet all the medical needs of an individual patient, from initial doctor visits to rehab after getting out of the hospital. When given the total fee up front, the primary care physicians in the organization are incentivized to spend more time with patients who need it and less with those who don’t; they prescribe tests, procedures and therapeutics when they’re really needed and can avoid them when they’re not; and they have the flexibility to channel resources into helping patients find the medical and social services they need to avoid expensive long-term complications that could put them in the most expensive healthcare setting possible — the hospital.

The healthcare system can never make up for the U.S.’s underfunded social safety net. But under capitation, it can hive off some of its resources to make up for its shortfalls and use its prestige and political clout to highlight its woeful inadequacies.

There are a growing number of start-up physician practices around the country that are embracing payment reform as the path to reinvigorating primary care. They include Iora Health, Oak Street Health, ChenMed, Aledade and others. Some health plans like Albany’s Capital District Physicians’ Health are working closely with affilialted primary care practices to deploy fully capitated payments for patients in their plan. But the sad reality is that 88% of primary care practices across the country receive less than a quarter of their revenue from such prospective payments.

The new crew at CMS

Last week, the Biden administration appointed Liz Fowler, former Senator Max Baucus’s top healthcare aid during the debates over the Affordable Care Act, to run the Center for Medicare and Medicaid Innovation. She played a key role in inserting the payment reform experiments run by CMMI into the law better known a Obamacare.

But over the last two years of the Trump administration, the number of healthcare organizations belonging to the Accountable Care Organizations, one such experiment created during the Obama years, fell sharply. Last year, CMS administrator Seema Verma stopped taking new applications entirely.

The pandemic has brought into bold relief the need for more drastic efforts at payment reform. The NEJM Perspective concluded that the pilot-project oriented, evolutionary approach taken during the Obama years needs to be jettisoned. It “paradoxically perpetuated FFS payment” and “exposed primary care practices to financially fatal risk” during the pandemic.

“Accelerating payment reform offers opportunities for rescuing primary care and resurrecting its promise as the foundation of a well-functioning U.S. health care delivery system,” the piece concluded.